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Deciphering the Mystery of Population Health Management

Meaningful use (MU) introduced us to population health in a big way. Improving population health is one of its overarching goals and there are many related objectives for managing it in stages 1 and 2. More, undoubtedly, will be added in stage 3, whenever it is finalized. Understanding this concept will be critically important to any health care stakeholder moving forward.

Point-of-Care Partners (POCP) advises as broad a base of such stakeholders as any firm its size. Our clients represent a veritable “who’s who” of payers: employers, health plans, pharmacy benefit managers, managed care organizations, drug knowledge-based companies, biopharma, federal and state government agencies, electronic health record (EHR) and tech companies, physician groups, accountable care organizations (ACOs), pharmacies and connectivity companies. For some, the simple explanation that population health is just “actionable lists” is enough. For most, that’s a nice start.

As a health information technology (health IT) strategy and management consulting firm, we help our clients manage the health of a population first by determining which technology is needed to support the various elements of population health management (PHM). We next consider appropriate context and means of managing necessary change.

To be sure, however, making PHM actionable is critically important. In our engagements, we start with the four pillars of PHM: communications, management, analytics and reporting. The health IT that is needed for each breaks down like this:

Health Communications. Health IT infrastructure is needed to “pull” consumers into active management of their health and connect the patient with his/her care team. Health IT facilitates notifications to patients and providers, as well as messaging among them.

Health Management. This combines most of the functions we think of with an EHR system, coupled with (1) disease registries that serve as “work lists” of patients having gaps in care, health risks etc., and (2) a patient portal connecting patients with their EHRs and having tools to help self-manage care.

Health Analytics. These are the “engines” driving health management and health communications because they will help us manage care as well as risk. The core includes clinical decision support rules engines that are enhanced to take into account the patient’s medical history, comorbidities, and health risk. Plus, new algorithms are emerging to predict risk in individual patients and subsets of the population needing various kinds of care, coupled with care recommendations that are based on that risk assessment.

Health Reporting. This simply is concurrent and retrospective quality scorecards, utilization and cost trends, etc. We have been doing this for some time, to a limited extent, but more will be required.

It’s easy to see that all of this quickly leads in a variety of new directions. So, where do we go next?

To be sure, current technology needs to evolve. More than 60% of physicians have attested to adopting EHRs, but the MU stage 1-certified EHRs of today only have pieces of the puzzle. As shown on the Office of the National Coordinator for Health Information Technology (ONC) Dashboard Quick-Stat #9, at the end of last year, key capabilities were missing in over 50% of EHRs.

On the positive side, today’s EHRs are pretty good at creating a problem list, assisting with care planning and providing clinical documentation and test results. In the communications arena, they can provide reminders, facilitate patient-provider messaging and present rules-based alerts and recommendations. They can also generate some quality-based reports required by Medicare, private payers and emerging ACOs. While this is a good start, more is obviously needed – both in terms of the technologies themselves as well as the broader environmental context. That is why savvy health care systems are pulling away from being EHR-centric and looking at the broader environment to address their technology and data requirements for PHM.

What’s needed is more complete and interoperable data, and the infrastructure to facilitate its exchange and use. In order to communicate, manage the patient’s condition(s), predict risk, support care processes and report on quality and outcomes, a complete record of data is needed. In the past quarter century, this has meant the merger of medical and pharmacy claims data. However, the end results do not present a complete picture of a patient’s health, clinical experience, costs and outcomes. As a result, a variety of data sources are needed. Health enterprise data are becoming more widely available, beyond what come from EHRs. This includes data that are self-reported by patients, patient portals and member panels. While such data may help provide pieces of the puzzle, they tend to be unstructured and not interoperable. Accuracy, reliability, privacy and security also can be problematic. Such issues must be addressed so the benefits of PHM may become a reality.

Finally, we need to manage all the transformation related to managing the health of populations. An important component is refocusing physicians’ mind-sets because PHM is uncharted territory. Physician training typically concentrates on dealing with the health of an individual patient, not managing the health of specific populations. Care is currently not organized around the concept of practicing in teams. Physicians’ roles are evolving within systems of care. As a result, they may end up working in areas in which they are no longer the expert or “guru” in charge. This does not need to be a bitter pill; however, change management will be crucial.

Vendors also will have to evolve to successfully address population health. POCP is tracking 40+ vendors supporting various areas of the health IT environment for PHM. Several support more than one area. For example, Wellcentive helps health care organizations manage populations with disease registries, gaps in care notifications, and a patient portal. Other EHR vendors are also moving quickly to support PHM. For example, Cerner has its Cerner Wellness solution, Allscripts has the FollowMyHealth product suite and Epic has MyChart and client integration with Health Catalyst.

All in all, population health management is adding a new dimension to the world of health IT. The earlier PHM is on your radar, the more competitive you’ll be in today’s rapidly evolving marketplace.